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Introduction: Several clinical studies have demonstrated the safety, feasibility, and efficacy of machine perfusion in liver transplantation, although its economic outcomes are still underexplored. This review aimed to examine the costs related to machine perfusion and its associated outcomes. Methods: Expert opinion of several groups representing different machine perfusion modalities. Critical analysis of the published literature reporting the economic outcomes of the most used techniques of machine perfusion in liver transplantation (normothermic and hypothermic ex situ machine perfusion and in situ normothermic regional perfusion). Results: Machine perfusion costs include disposable components of the perfusion device, perfusate components, personnel and facility fees, and depreciation of the perfusion device or device lease fee. The limited current literature suggests that although this upfront cost varies between perfusion modalities, its use is highly likely to be cost-effective. Optimization of the donor liver utilization rate, local conditions of transplant programs (long waiting list times and higher MELD scores), a decreased rate of complications, changes in logistics, and length of hospital stay are potential cost savings points that must highlight the expected benefits of this intervention. An additional unaccounted factor is that machine perfusion optimizing donor organ utilization allows patients to be transplanted earlier, avoiding clinical deterioration while on the waiting list and the costs associated with hospital admissions and other required procedures. Conclusion: So far, the clinical benefits have guided machine perfusion implementation in liver transplantation. Albeit there is data suggesting the economic benefit of the technique, further investigation of its costs to healthcare systems and society and associated outcomes is needed.

BACKGROUND In context of suboptimal liver utilisation, grafts with various risk factors are under consideration today. For example, impaired vascularity with severe arterial calcifications and modified liver shapes are no longer contraindications and their use depends on the centre policy and experience of the surgical team. Riedel liver lobes represent a tongue-like liver shape with inferior projection in the right liver lobe. Such development modifications were initially described when patients developed a lesion and subsequently presented with symptoms. We here present the first case report in the literature, where such livers with anatomical variations were used for transplantation. CASE SUMMARY We describe here two cases of adult human liver transplantation, where we have accepted two donor livers with modified shape. The technical considerations for transplantation of such livers, found with enlarged right lobes, or Riedel shape, and hypo-trophic left lateral segment are highlighted. Both recipients experienced immediate liver function and overall good outcomes with a minimum follow up of 1 year. We also provide detailed pictures and outcome analysis in combination with a literature review. CONCLUSION The utilisation of donor livers with modified shape, such as Riedel’s Lobe appears safe and will increase the donor pool.

Post-operative pancreatic fistula (POPF) is a major cause of morbidity following pancreatoduodenectomy. The risk of POPF varies between individuals and thus assessment without risk adjustment is crude. However, despite the availability of numerous scores to determine risk, no study has provided a risk adjusted assessment of POPF outcomes.The observed and risk adjusted occurrence of POPF from consecutive patients operated upon by eight surgeons were recorded. Surgeons varied in experience from newly appointed (n = 5) to established (n = 3). CUSUM (cumulative sum) analysis was used to assess performance.104 POPF occurred among 519 patients (20.0%). The occurrence of POPF was significantly lower among experienced surgeons (20/186, 10.7% vs 84/333, 25.2%; p 0.001). Following risk adjustment surgeons observed 16.6 fewer to 6.5 excess POPF per 100 patients than predicted. Analysis of the CUSUM plots demonstrated the experienced surgeons performed steadily with a gradual reduction in observed POPF compared to what was predicted. The new surgeon's performance was less consistent and evidence of a learning curve was observed with steady improvement occurring after 50-70 patients.Risk adjusted assessment of POPF demonstrates differences between experienced and less experienced surgeons. This method could be used to audit practice and observe effects of changes to technique.

AIM To review the clinical impact of machine perfusion (MP) of the liver on biliary complications post-transplantation, particularly ischaemic-type biliary lesions (ITBL). METHODS This systematic review was performed in accordance with the Preferred Reporting Systematic Reviews and Meta-Analysis (PRISMA) protocol. The following databases were searched: PubMed, MEDLINE and Scopus. The keyword “liver transplantation” was used in combination with the free term “machine perfusion”. Clinical studies reporting results of transplantation of donor human livers following ex situ or in situ MP were analysed. Details relating to donor characteristics, recipients, technique of MP performed and post-operative biliary complications (ITBL, bile leak and anastomotic strictures) were critically analysed. RESULTS Fifteen articles were considered to fit the criteria for this review. Ex situ normothermic MP was used in 6 studies, ex situ hypothermic MP in 5 studies and the other 4 studies investigated in situ normothermic regional perfusion (NRP) and controlled oxygenated rewarming. MP techniques which have per se the potential to alleviate ischaemia-reperfusion injury: Such as hypothermic MP and NRP, have also reported lower rates of ITBL. Other biliary complications, such as biliary leak and anastomotic biliary strictures, are reported with similar incidences with all MP techniques. There is currently less clinical evidence available to support normothermic MP as a mitigator of biliary complications following liver transplantation. On the other hand, restoration of organ to full metabolism during normothermic MP allows assessment of hepatobiliary function before transplantation, although universally accepted criteria have yet to be validated. CONCLUSION MP of the liver has the potential to have a positive impact on post-transplant biliary complications, specifically ITBL, and expand extended criteria donor livers utilisation.

Unplanned hospital readmission after pancreaticoduodenectomy (PD) is usually due to surgical complications and has significant clinical and economic impact. This study developed a risk score to predict 30-day readmission after PD.Patients undergoing PD between 2009 and 2016 were reviewed from a prospective database. Predictors of readmission were identified using a multivariable logistic regression model, from which a points-based risk scoring system was derived.81 of 518 patients (15.6%) were readmitted within 30 days. History of cardiac disease ([odds ratio] OR = 2.12; 95% CI: 1.12-4.56), CRP140 mg/L on post-operative day 3 (OR = 2.34; 95% CI: 1.37-4.35) and comprehensive complication index14 (OR = 1.74; 95% CI: 1.03-2.85) were independent predictors of readmission. The regression coefficients were used to generate a risk score with excellent calibration (p = 0.917) and good discrimination (c-index = 0.65; 95% CI: 0.58-0.71; p 0.001). Patients were categorised as low, moderate and high risk, with readmission rates of 6.4%, 13.4% and 23.0% respectively (p 0.001).The risk score identifies patients at high risk of readmission after pancreaticoduodenectomy. Such patients may benefit from pre-discharge imaging and/or enhanced follow-up, which may potentially reduce the impact of readmissions.